Background. There is a scarcity of data on the consequences of coronavirus disease-19 (COVID-19) infections in kidney transplant recipients (KTRs) from emerging countries. Methods. Here, we present a cohort study of 13 transplant centers in India including 250 KTR (226 living and 24 deceased donors) with polymerase chain reaction-confirmed COVID-19 positivity from March 23, 2020, until September 15, 2020. We detailed demographics, immunosuppression regimen, clinical profile, treatment, and outcomes. Results. Median age of transplant recipients was 43 years, and recipients presented at a median of 3.5 years after transplant. Most common comorbidities (94%) included arterial hypertension (84%) and diabetes (32%); presenting symptoms at the time of COVID-19 included fever (88%), cough (72%), and sputum production (52%). Clinical severity ranged from asymptomatic (6%), mild (60%), and moderate (20%) to severe (14%). Strategies to modify immunosuppressants included discontinuation of antimetabolites without changes in calcineurin inhibitors and steroids (60%). Risk factors for mortality included older age; dyspnea; severe disease; obesity; allograft dysfunction before COVID-19 infection; acute kidney injury; higher levels of inflammatory markers including C-reactive protein, interleukin-6 level, and procalcitonin; chest X-ray abnormality, and intensive care unit/ventilator requirements. Overall patient mortality was 11.6% (29 of 250), 14.5% (29 of 200) in hospitalized patients, 47% (25 of 53) in intensive care unit patients, and 96.7% (29 of 30) in patients requiring ventilation. KTRs with mild COVID-19 symptoms (n = 50) were managed as outpatients to optimize the utilization of scarce resources during the COVID-19 pandemic. Conclusions. Mortality rates in COVID-19-positive KTR appear to be higher than those in nonimmunosuppressed patients, and high mortality was noted among those requiring intensive care and those on ventilator.

As the coronavirus disease 2019 (COVID‐19) pandemic spread across the globe, transplant programs suffered a setback. We report the first experience of COVID‐19 infection within 1 month of living donor kidney transplant (LDKT). We describe 2 LDKT recipients who were detected positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection at day 19 and day 7 posttransplant. They had minimal symptoms at diagnosis and did not develop any respiratory complications or allograft dysfunction. Immunosuppression was de‐escalated; however, nasopharyngeal swab real‐time reverse transcription polymerase chain reaction (rRT‐PCR) remained positive for SARS‐CoV‐2 for a prolonged time. Younger age, absence of other comorbidities, and lower dose of anti‐thymocyte globulin (ATG) used as induction possibly contributed to good outcome in our recent LDKT recipients compared with earlier published cases of recent deceased donor kidney transplant recipients with COVID‐19.

Background. There is limited current knowledge on feasibility and safety of kidney transplantation in coronavirus disease-19 (COVID-19) survivors. Methods. We present a retrospective cohort study of 75 kidney transplants in patients who recovered from polymerase chain reaction (PCR)-confirmed COVID-19 performed across 22 transplant centers in India from July 3, 2020, to January 31, 2021. We detail demographics, clinical manifestations, immunosuppression regimen, laboratory findings, treatment, and outcomes. Patients with a previous diagnosis of COVID-19 were accepted after documenting 2 negative severe acute respiratory syndrome coronavirus 2 PCR tests, normal chest imaging with complete resolution of symptom for at least 28 d and significant social distancing for 14 d before surgery. Results. Clinical severity in patients ranged from asymptomatic (n = 17, 22.7%), mild (n = 36.48%), moderate (n = 15.20%), and severe (n = 7.9.3%) disease. Median duration between PCR positive to transplant was 60 d (overall) and increased significantly from asymptomatic, mild, moderate, and severe disease (49, 57, 83, 94 d, P 0.019), respectively. All recipients and donors were asymptomatic with normal creatinine after surgery at a median (interquartile range) follow-up of 81 (56-117) d without any complications relating to surgery or COVID-19. Patient and graft survival was 100%, and acute rejection was reported in 6.6%. Conclusions. Prospective kidney transplant recipients post-COVID-19 can be considered for transplantation after comprehensive donor and recipient screening before surgery using a combination of clinical, radiologic, and laboratory criteria, careful pretransplant evaluation, and individualized risk-benefit analysis. Further large-scale prospective studies with longer follow-up will better clarify our initial findings. To date, this remains the first and the largest study of kidney transplantation in COVID-19 survivors.

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Background: In the current coronavirus 2019 (COVID-19) pandemic, hemodialysis patients are at increased risk of acquiring COVID-19 infection. Many patients awaiting transplant may have already contracted COVID-19 infection. Hence, deciding the "right time" to transplant is important. Methods: We describe the first case report of a patient who recovered from severe COVID-19 infection and later successfully underwent living donor ABO incompatible (ABOi) kidney transplant (KT). Results: A 46-year-old man on hemodialysis was planned for ABOi KT, with mother as prospective donor. Unfortunately, the patient developed COVID-19 pneumonia on May 11, 2020 and required intensive care unit care with noninvasive ventilator support in the second week of infection. He recovered clinically and nasopharyngeal swab was negative on June 14, 2020. However, due to persistently high C-reactive protein (CRP) and D-dimer, we waited for additional 2 months after COVID-19 negative report till markers had settled. By this time, markers had decreased from peak CRP 67.55 mg/L and D-dimer 3,970 ng/mL to nadir CRP 6.9 mg/L and D-dimer 881 ng/mL. high. Baseline anti-B titers were IgM 1:64 and IgG 1:2048. Three plasma exchange sessions and one session of 7.5 hours of double filtration plasmapheresis were done. Anti-B antibody titers decreased to IgM nil and IgG 1:4 and he underwent B to O blood group ABOi KT on August 14, 2020. Surgery and post-transplant period were uneventful. At 1-month post-transplant, his serum creatinine was 1.03 mg/dL. Conclusions: In recent COVID-19 recovered patients undergoing KT, ongoing inflammatory and procoagulatory states are additional risk factors for rejection and acute tubular injury. We suggest monitoring of inflammatory and procoagulatory markers in post-COVID-19 infection period and to plan KT only after these markers have settled. In high risk ABOi transplant, the use of anti-blood group immunoadsorption column offers selective removal of anti-blood group antibodies and would theoretically preserve the protective anti-COVID-19 antibodies.

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Recent "in vitro" studies describe nucleoside diphosphate-linked moiety X-type motif 15 (NUDT15) enzyme to be involved in the metabolism of ganciclovir. 1,2 We report severe leukopenia during therapy with valganciclovir in a recent kidney transplant recipient with NUDT15 genetic variation. This case report is the first to substantiate a theoretical postulate of increased valganciclovir toxicity with NUDT15 variation.

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